Basic Information
| Provider Information | |||||||||
| NPI: | 1417955402 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BOSTON PLASTIC SURGERY ASSOCIATES, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 340 MAIN ST | ||||||||
| Address2: | STE. 670 | ||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016081604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5087543566 | ||||||||
| FaxNumber: | 5084386364 | ||||||||
| Practice Location | |||||||||
| Address1: | 1153 CENTRE ST | ||||||||
| Address2: | SUITE 5790 | ||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021303446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6175220008 | ||||||||
| FaxNumber: | 6175222587 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2005 | ||||||||
| LastUpdateDate: | 10/04/2011 | ||||||||
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| AuthorizedOfficialLastName: | PITTS | ||||||||
| AuthorizedOfficialFirstName: | ELEANOR | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 6175220008 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2082S0099X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Plastic Surgery | Plastic Surgery Within the Head and Neck | 2082S0105X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Plastic Surgery | Surgery of the Hand | 2086S0122X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Plastic and Reconstructive Surgery | 208200000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Plastic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 9783261 | 05 | MA | MEDICAID |